Emergency Info

In an emergency, please contact: *

Phone # *

Physician’s Name *

Phone # *

Insurance Company

Phone #

ID#

Group/Policy #

Consent *

In the event of an emergency or non-emergency situation requiring medical treatment for the child specified above, I grant Homes of Hope permission for any and all medical, and/or dental attention to be administered to my child in the event of an injury or illness. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. This box constitutes my signature.I Agree/Signature

Verification

Please enter any two digits *Example: 12

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Homes of Hope, a Christian Non-Profit Corporation, is a 501(c)(3) tax exempt organization. Donations and contributions are tax-deductible as allowed by law. Homes of Hope relies on grants, private donations, volunteers and community support.About Homes of Hope